If you've started reading about hormone therapy for menopause, you've probably run into a wall of terms: estrogen-only, combined, transdermal, bioidentical, systemic, vaginal. It can feel like everyone's speaking a different language. Here at Menova we sell no hormones and we're not a medical provider, so we have no reason to nudge you toward anything. This is just a plain-spoken map of the landscape, so the conversation with your own clinician makes more sense.

Hormone therapy (often called HRT or MHT, menopausal hormone therapy) generally comes down to two big questions: which hormones, and how they get into your body.

Estrogen and progestogen: which hormones and why

Let's start with the hormones.

Estrogen is the main player. It's the hormone that tends to ease classic symptoms like hot flashes, night sweats, and disrupted sleep, and it can help with vaginal dryness. The most common estrogen used today is estradiol, which is chemically identical to the estrogen your own body made before menopause. That's worth knowing because of the "bioidentical" buzzword, more on that in a moment.

So why does the progestogen part exist? It comes down to your uterus. When estrogen acts on the lining of the uterus (the endometrium) without anything to balance it, that lining can build up too much, a problem called endometrial hyperplasia, which raises the risk of endometrial cancer over time. A progestogen (the umbrella term for progesterone and progestin-type hormones) keeps that lining in check. According to ACOG and The Menopause Society, this is the core reason the two are paired.

That leads to a simple rule of thumb clinicians use:

  • If you still have your uterus, systemic estrogen is generally combined with a progestogen to protect the lining.
  • If you've had a hysterectomy (no uterus), estrogen-only therapy is typically appropriate, because there's no lining to protect.

This is general education, not a verdict on your situation, but it explains why your friend on estrogen-only and you on a combined product might both be doing exactly the right thing.

What "bioidentical" hormones really mean

A quick word on "bioidentical," because the marketing around it gets murky. Bioidentical simply means the hormone matches what your body makes. The key thing many people don't realize: FDA-approved bioidentical options already exist. Estradiol (in patches, gels, sprays, pills, and vaginal forms) and micronized progesterone are bioidentical and FDA-approved. There's even an FDA-approved combined estradiol-plus-progesterone pill (Bijuva). That's different from custom-mixed "compounded bioidentical" products, which ACOG and the Endocrine Society note are generally not FDA-approved and lack the same testing for purity and dosing. So "bioidentical" and "FDA-approved" are not opposites, you can have both.

Now, the second question: how the hormone is delivered. This is where patch, gel, pill, and vaginal forms come in.

HRT forms: pill, patch, gel, and spray

Systemic forms send estrogen throughout the body to address whole-body symptoms like hot flashes:

  1. Pill (oral): A daily tablet, familiar and simple. Because it's swallowed, it passes through the liver first ("first-pass" metabolism), which influences clotting factors.
  2. Patch (transdermal): A sticky patch worn on the skin, changed on a schedule. It sends estrogen straight into the bloodstream and skips that first liver pass.
  3. Gel or spray (transdermal): Applied to the skin daily; same skip-the-liver idea as the patch, with more day-to-day flexibility for some people.

The transdermal-versus-oral discussion is one of the most common in menopause care. The general pattern researchers describe: oral estrogen's trip through the liver appears to raise the risk of blood clots (venous thromboembolism), and oral estrogen is also linked with higher stroke risk, while transdermal (skin) forms largely avoid that first-pass effect and are often discussed as a lower-clot-risk option, particularly for people with certain risk factors. NICE guidance and The Menopause Society have both highlighted this distinction. For relieving symptoms, studies suggest oral and transdermal can be similarly effective, so the choice often hinges on personal risk factors and preference rather than one being universally "better."

Vaginal estrogen: a separate, low-dose option

Then there's vaginal estrogen, which is its own category. Delivered as a cream, tablet, insert, or ring placed locally, it's low-dose and aimed mainly at vaginal dryness, irritation, and painful sex, without flooding the whole body the way systemic forms do. People sometimes use it alongside, or instead of, systemic therapy.

None of this tells you what's right for you, and that's the point. Your medical history, clot risk, whether you have a uterus, and which symptoms bother you most all shape the picture. If you're trying to get your bearings before a clinician visit, Menova's free self-check can help you organize what you're feeling into something concrete to talk through.

This article is general education, not medical advice. It can't diagnose you or tell you which hormone, form, or dose is right, only a licensed clinician who knows your full history can do that. Bring your questions to that conversation.

Sources: ACOG: Compounded Bioidentical Menopausal Hormone Therapy; The Menopause Society; U.S. FDA: Hormone Replacement Therapies; NIH/NCBI: Hormone Replacement Therapy (StatPearls).